Is menopause hormone therapy right for you?
The transition to menopause is a natural and normal part of life, but that doesn't mean it's easy.
Posted — UpdatedFor some, these symptoms are subtle and short-lived; for others, they are debilitating and can last for years.
“There’s an idea that women have to power through these symptoms, and there’s a culture of dismissing some of these concerns,” says UNC Health OB-GYN Katelin Zahn, MD. “It’s important that women mention these symptoms to their provider.”
UNC Health OB-GYN Rachel Urrutia, MD, adds, “These symptoms might not be life-threatening, but they can significantly impact relationships and the ability to enjoy daily activities. If you’re not sleeping, you’re feeling depressed and you can’t concentrate, it will affect your quality of life.”
One option for relieving menopausal symptoms is hormone therapy. Drs. Zahn and Urrutia explain the hormonal changes happening during menopause and how hormone therapy can help.
Hormonal changes around menopause
You can expect a variety of hormonal changes during perimenopause, the term for the four to eight years leading up to and including the year after your last period.
Dr. Urrutia says, “In the years leading up to menopause, your ovaries are less responsive to brain hormones that tell them to ovulate. Your brain may send out extra hormones to try to stimulate ovulation, and if the ovaries respond, there can be higher levels of estrogen some months.”
“The body has a thermostat in the hypothalamus, and input to this thermostat is sensitive to estrogen,” Dr. Zahn says. “Vasomotor symptoms like hot flashes and night sweats are the result of that thermostat responding to changing estrogen.”
People tend to have symptoms most intensely in the two years before the last cycle and right after, though some have them for longer.
Hormone therapy during menopause
“Estrogen has the most impact on hot flashes and night sweats, but progestin may help with mood stabilization and sleep,” Dr. Urrutia says. “The dosing typically involves estrogen every day, and then either a small amount of progestin daily or a larger amount of progestin for 10 to 12 days each month.”
If you still have a uterus, a form of progesterone is an important part of hormone therapy, as it protects the lining of the uterus from cancers that could form from excess estrogen.
Your provider will determine the amount of hormones necessary and the way they’re administered, depending on your needs and symptoms. You may apply a skin patch, take a pill, or use a gel, spray or vaginal ring.
“When we prescribe menopause hormone therapy, we’ll see the person around six weeks later to see if symptoms have been relieved and they’re on the right dose,” Dr. Zahn says. “Then, we would see the person each year to analyze any new medical concerns and determine whether it’s safe to continue the hormone therapy.”
Dr. Urrutia says, “We’re looking to help symptoms with the smallest dose. There may be a time of trial as we see how they feel.”
If you have vaginal and urinary symptoms related to menopause, including vaginal dryness, pain with intercourse or urinary irritation, local hormone therapy is an option. Rather than taking a dose that affects the entire body, you can use a low-dose estrogen cream, tablet or ring in the vagina to relieve symptoms. This method of hormone therapy is associated with lower health risks than systemic hormone therapy.
Hormone therapy risks
Hormone therapy can increase your risk of certain conditions, so your doctor will help you assess the benefits of symptom relief against your health history.
“The risk for a blood clot doubles on estrogen,” Dr. Urrutia says. “People in their 40s and 50s generally have a very low risk for blood clots, but it is an increase.”
“The risk seems to be specific to people using hormones for more than five years, so we might have people use the therapy for four years and then consider tapering off, particularly people with a family history of breast cancer,” Dr. Urrutia says.
If you need symptom relief for longer than five years, talk to your doctor about a plan.
“We know that a third of women will have bothersome symptoms for longer than 10 years,” Dr. Zahn says. “While there used to be a hard stop at five years, we can consider extending the therapy if the benefits outweigh the risk.”
If you are at a higher risk of heart attack or stroke, you may not be a good candidate for hormone therapy, though age is an important consideration.
Alternatives to hormone therapy
Besides medications, cognitive behavioral therapy and clinical hypnosis can be effective in managing hot flashes.
Other options are available but don’t have as much evidence supporting their efficacy.
“There’s a booming industry of supplements related to menopausal symptoms right now, but there’s not much data on how well they work,” Dr. Zahn says. “Some of these supplement subscriptions are very expensive, and your money can be more valuably spent on something with more evidence.”